Healthcare Provider Details

I. General information

NPI: 1710757471
Provider Name (Legal Business Name): LAGRANGE FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S DETROIT ST
LAGRANGE IN
46761-2314
US

IV. Provider business mailing address

612 S DETROIT ST
LAGRANGE IN
46761-2314
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KALYSSA BONTRAGER
Title or Position: OWNER/ DOCTOR
Credential:
Phone: 260-463-2111